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JAN-20-2012 11:08 Se*e Station Systems 408 938 8888 P.03 Monitoring System. ipment Certiffication Far Use By All,lurisdirtions Within The State of Califnrnia Authority Cited Chapter 6.7, Health and Safety Code; Chapter/G, Division 3, Title 23, California Code nrRegulratioan This form must be used to document testing and servicing of monitoring equipment. A separate certification or rgggrt must be prepared for each monitoring 5ysternl control Rgncl by the technician who performs the work. A copy of this form must he provided to the rank system owner/operator. The owner/operator must,submit a copy of this form to the local agency regulating UST system within 30 days of test date, A. General Information Facility Name:Tracy Blvd Shell 8, Mini Mart Bldg.No.: Site Address: 3725 N.Tracy Blvd. City: Trac ,CA Zip: 95376 Facility Contact Person: Manager Contact Phone No.: (209)835-7608 Make/Model of Monitoring System: !//R Simplicity Date of Tcsting/Survicing: 115112 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced. Tank I%01-Regu Tank IIZ: 02-Pius ❑ In-Tank Gauging Probe. Model: VR 847380.107 ❑ In-Tank Gauging Probe. Model: VR 847390-107 Cl Annular Space or Vault Sensor. Model: VR 794380.3D1 Annular Space or Vault Sensor. Model:_ VR 794380-301 ® Piping Sump\Trench Sensor(s). Model: VR 794380-208 Piping Sump\Trench Sensor(s), Modcl; VR 794384-208 Fill Sump Sensor(s). Model: VR 794384-208 ® Fill Sump Sensor(s). Model: VR 7$4490-zea ❑ Mechanical Line Leak Detector, Model: ❑ Mechanical line teak Detector. Model: ® Electronic Line Leak Detector, Model: VR Series 8484 Electronic Linc Leak Detector. Model; VR UK"8484 ❑ Tank Overfill\High-Level Sensor. Model: p Tank OvcrPil\liigh•l.-evil Sensor. Model: _ p Other(specify equipment type acrid rncKlcl in Section E on PaAc 2). ❑ Other(.specify equipment type and model in Scetion ti on Mage 2). Tank i ; 03-Pram Tank I . 03-Diesel ❑ In-Tank Gauging Probe. Model: VR 847390-107 ❑ in-Tank Gauging Probe. Model: VR 847390-107 Annular Space or Vault Sensor, Model: Vex 70430-301 ® Annular Space or Vault Sensor. Model: VWM4350491 W Piping Sump\Trench Sensor(s), Model: VR 744380.209 Piping Sump\Trench Sensor(s), Model; VR 7$4390208 !s Fill Sutnp Sensor(s), Model: VR 784380-208 bill Sump Sensor(s), Model: VR 794380.208 ❑ Mechanical Linc Leak Detector. Model: Mechanical Line Leak Detector, Model: C1 FJcctronie Line freak Detector. Model: VR series 8484 ® Electronic Line Leak Detector, Model: VR ser,ae 4404 ❑ Tank Overfill\High-Level Sensor. Model; ❑ Tank(Overfill\High-Levei Sensor. Model: _ ❑ Other(specify equipment type and model in Section E on Page 2), ❑ Other(specify equipment type and model in Section F on Page 2)• Dispenser TI)• Dispenser IU• ❑ Dispenser Containment Sensor(s), Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valves(s), Q Shear Valve(s), ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID- Dispenser ID• ❑ Dispenser Containment Sensor(s). Model: [7 Dispenser Conmintnent Sensor(s), Model! _ ❑ Shear Valve(s). ❑ Shear Valve(s). Q .Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chtain(s), Dispenser IIi: I Dispenser TD: ❑ Dispenser Containment Sensor(s), Model; ❑ Dispenser Containment Sensor(s). Model: _ ❑ Shear valve(s), Shear valve(s), ❑ Dispenser Containment Float(s)and Chain(s). ❑ Disponser Containment Float(s)and Chain(s). *if the f:wility contains mom tanks or dispensers,copy this form.Include information for every tank and dispenser at the facility C.Certification- I certify that the equipment identitiLd in this document was inspected/serviced in accordance with the rtlannfeeturer's guidelines. Attached to this Certlfleation Is information(e g,manufactures'checklists)ncccmry to verify that Ibis Information Is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the; (check all that apply): ❑ System set-up ❑ Alarm history report Technician Name(print); Randy Wilkerson Signature: L&L_ Mfg.Cert.#6.: A32404 TCG# 5258560-UT License.No,: 485184 Testing Company Name: Service Station Systems Phone No.: (408)971-2445 Testing Company Address: 680 Quinn Ave., San Jose,CA 95112 Date of Tcsting/Servicing: 1/5/12